Delay in Timely Incontinence Care Response
Penalty
Summary
Facility staff failed to provide timely incontinence care for a resident who was unable to perform activities of daily living independently. The resident, who had multiple chronic health conditions including cerebral infarction, diabetes, heart failure, and a history of prostate cancer, was assessed as cognitively intact but occasionally incontinent of bladder and frequently incontinent of bowel. On the morning in question, the resident spilled urine while using a urinal and soiled both his brief and bed sheets. He activated the call bell for assistance around 5:00 to 5:30 a.m. and waited approximately 35 to 40 minutes before a certified nurse's aide (CNA) responded to his request for help. The CNA assigned to the resident's care acknowledged that she was occupied with another resident who had an early appointment and required extensive assistance, which delayed her response. The CNA informed the resident of the delay and stated that the resident agreed to wait. However, the resident later expressed dissatisfaction with the wait time, stating that staff should have responded sooner given his condition. The CNA did not seek assistance from other staff members, and the nurse on duty was aware of the resident's request but did not intervene. Facility policy on answering call lights requires staff to make reasonable efforts to ensure timely responses to residents' needs, with response time determined by the urgency of the situation. The resident's care plan specified the need for assistance with activities of daily living, including incontinence care, and directed staff to change briefs every two hours and as needed. Despite these guidelines, the resident experienced a significant delay in receiving necessary care, as confirmed by staff interviews and facility documentation.